Hospitalization records during monkeypox outbreaks: a scientific report from the available documents
Authors: Mohsen Karbalaei, Masoud Keikha
Journal: International Journal of Surgery (2023)

Dear Editor, Monkeypox virus (MPXV) is a rare zoonotic virus belonging to the Orthopoxvirus family. As of September 2022, over 43 600 confirmed monkeypox (MPX) cases have been reported in more than 90 different countries beyond African territories. The first documented human deaths of MPX in recent outbreaks outside of Africa have been reported in Brazil, India, Ecuador, Spain, and Cuba. Human MPX is a self-limiting neglected tropical disease with two clinical stages of illness: first stage, fever, myalgia, chills, sore throat; second stage, lymphadenopathy associated with skin eruption after fever1. According to available documents, we found that nine of 34 laboratory-confirmed cases of MPX during the 2003 outbreak in the USA required hospitalization; two cases of MPX required ICU admission due to encephalitis as well as retropharyngeal abscess2. Furthermore, complications, for example, bacterial superinfection and keratitis with corneal ulceration were also reported from hospitalized patients suffering MPX3. Unfortunately, MPXV outbreak is spreading in several countries around the world, while there is limited information on the epidemiological changes and clinical aspects of its outbreak. Herein, we discuss hospitalization due to MPXV 2022 outbreak using previous observations beyond the African continent. In recent year, Thornhill et al.4 reported the clinical features of 528 MPXV infections between April 27 and June 24 in the European Union; according to their report, 70 (13%) cases were hospitalized (without mortality) following pain management, soft tissue superinfection, pharyngitis, eye lesions, acute kidney injury, as well as myocarditis. Moschese et al.5 reported four cases of 34 confirmed human MPX cases (11.7%) that required hospitalization (without mortality) due to pain and bacterial superinfections particularly cellulitis for 5–13 days; ∼50% of hospitalized cases were HIV-positive and skin lesions was observed in their head, limbs, trunk, face, perianal, penis, as well as scrotum. Catala et al.6 showed that four out of 185 patients (2%) required hospitalization due to several complications such as pain, severe dysphagia, conjunctival disease, and colonic perforation; three of these cases were HIV-positive, and no death was reported from this study. In another study from Germany, five cases of 16 confirmed MPXV-infected individuals were hospitalized; bacterial coinfection was confirmed in two of five hospitalized cases, in addition, 40% of hospitalized patients were HIV-positive7. Hammerschlag et al8, in 2022, reported a hospitalized case of MPX in Australia due to painful bacterial cellulitis in the anogenital area; he was an HIV-positive man, and his skin lesions and nasopharyngeal swab samples were positive for MPXV during hospitalization. However, in some countries such as South Korea, to prevent the spread of infection, the patient was hospitalized in a room, although the clinical symptoms of the patient was normal9. Interestingly, Mailhe and colleagues reported 17 hospitalized MPX cases (17/264, 6%), and four cases were HIV-positive. These cases required hospitalization due to various complications, for example, pain, colitis, rectitis, necrotic cellulitis, paronychia, digestive involvement, noncardia angina with dysphagia, blepharitis, as well as keratitis; one hospitalized case had a history of smallpox vaccination10. Finally, Benites-Zapata and colleagues in 2022 performed a meta-analysis on the clinical relevance of the MPX 2022 outbreak; they measured the pooled prevalence of hospitalization at 35% (95% CI: 14–59%), and 4% of those progressed to fetal outcomes. Based on their study, complications associated with MPX include ocular lesions, secondary bacterial skin infections, pain, hemorrhagic pustules, as well as ulcerated or necrotic lesions11. Our literature review revealed that adverse clinical outcomes of MPX, particularly hospitalization, may have occurred in addition to the fact that MPX is a self-limiting disease. Our review indicated the presence of centrifugal skin rashes in the face, limbs, trunk, back, and penile of hospitalized MPX cases. A large proportion of hospitalizations due to this disease are related to superficial bacterial infection, pain management, ocular lesions, sore throat, dysphagia, as well as infection control4,5. In addition, there are also MPX cases that had experienced other complications such as colitis, rectitis, and colonic perforation due to traumatic anal sex, particularly in men who have sex with men group6. However, possible worsening of MPX infection due to MPXV alone is ucommon. Interestingly, it is possible that MPXV will be detected in all samples from skin rashes, blood, anogenital lesions, respiratory secretion, as well as seminal samples during the period of hospitalization5–8. We speculate that a large proportion of hospitalized MPX cases are HIV-positive. However, Nörz et al12. demonstrated contamination with 105 viral copies/cm2 of MPXV on inanimate room surfaces; this virus can be successfully isolated from surfaces with more than 106 copies. Our recent data recommend the need for protective measures in hospital staff, definitely preexposure or early postexposure vaccination. According to recent studies, MPX patients received drugs such as antibiotics, acetaminophen, opioids, tecovirimat, and cidofovir. Fortunately, no deaths were reported in any of the studies. Ethical approval None. Sources of funding None. Authors’ contribution All authors read and approved the final version of the manuscript. Conflicts of interest disclosure The authors declare that they have no financial conflict of interest with regard to the content of this report. Research registration unique identifying number (UIN) None. Guarantor All the authors of this paper accept full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish. Provenance and peer review Not commissioned, externally peer reviewed.